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ACSMS CERTIFIED NEWS JULYSEPTEMBER 2010 VOLUME 20:3 1 ACSMS CERTIFIED NEWS JANUARY-MARCH 2010 VOLUME 20:1 1

NEWS
Continuing Education Self-Tests
page 15
Are Your Assessments
Providing The Information
You Need? page 3
Is Functional Training
Really Functional? page 5
New Thoughts On
What Really Causes
Heart Disease page 7
Resistance, Repetitions
and Results page 10
A Perspective On
Lower Extremity
Peripheral Arterial
Disease and Exercise
page 12
The Evolution of
Worksite Wellness
page 14
ACSMS CERTIFIED
A Perspective On
Lower Extremity
Peripheral Arterial
Disease and Exercise
page 12
The Evolution of
Worksite Wellness
page 14
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J U L Y S E P T E M B E R , 2 0 1 0 V O L U M E 2 0 ; I S S U E 3
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2 ACSMS CERTIFIED NEWS JULYSEPTEMBER 2010 VOLUME 20:3
ACSMS CERTIFIED NEWS
JulySeptember 2010 VOLUME 20, ISSUE 3
In this Issue
Fitness Assessment and Exercise Prescription:
Are your assessments providing the
information you need? .......................................... 3
Is Functional Training Really Functional?.............. 5
New Thoughts on What Really Causes
Heart Disease and How Exercise Helps
Beyond Traditional Risk Factors .......................... 7
Coaching News........................................................... 9
Resistance, Repetitions and Results ...........................10
A Perspective on Lower Extremity Peripheral
Arterial Disease and Exercise ................................12
The Evolution of Worksite Wellness: Enhancing
Quality of Life from 9 to 5 and Beyond .............14
Self-Tests ........................................................................15
Co-Editors
Paul Sorace, M.S.; James R. Churilla, Ph.D., M.P.H.
Committee on Certification
and Registry Boards Chair
Madeline Bayles, Ph.D., FACSM
CCRB Publications Subcommittee Chair
Paul Sorace, M.S.
ACSM National Center Certified News Staff
National Director of Certification
and Registry Programs
Richard Cotton
Assistant Director of Certification
Traci Sue Rush
Professional Education Coordinator
Shaina Miller
Publications Manager
David Brewer
Editorial Board
Chris Berger, Ph.D.
Clinton Brawner, M.S., FACSM
Brian Coyne, M.Ed.
Avery Faigenbaum, Ed.D., FACSM
Yuri Feito, M.S., M.P.H.
Tom LaFontaine, Ph.D., FACSM
Peter Magyari, Ph.D.
Thomas Mahady, M.S.
Jacalyn McComb, Ph.D., FACSM
Peter Ronai, M.S.
Larry Verity, Ph.D., FACSM
Stella Volpe, Ph.D., FACSM
Jan Wallace, Ph.D., FACSM
For More Certification Resources Contact the
ACSM Certification Resource Center:
1-800-486-5643
Information for Subscribers
Correspondence Regarding Editorial Content
Should be Addressed to:
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E-mail: certification@acsm.org
Tel.: (317) 637-9200, ext. 115
For back issues and author guidelines visit:
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ACSMs Certified News (ISSN# 1056-9677) is published
quarterly by the American College of Sports Medicine
Committee on Certification and Registry Boards (CCRB). All
issues are published electronically and in print. The articles
published in ACSMs Certified News have been carefully
reviewed, but have not been submitted for consideration as, and
therefore are not, official pronouncements, policies,
statements, or opinions of ACSM. Information published in
ACSMs Certified News is not necessarily the position of the
American College of Sports Medicine or the Committee on
Certification and Registry Boards. The purpose of this
publication is to provide continuing education materials to the
certified exercise and health professional and to inform these
individuals about activities of ACSM and their profession.
Information presented here is not intended to be information
supplemental to the ACSMs Guidelines for Exercise Testing and
Prescription or the established positions of ACSM. ACSMs
Certified News is copyrighted by the American College of
Sports Medicine. No portion(s) of the work(s) may be
reproduced without written consent from the Publisher.
Permission to reproduce copies of articles for noncommercial
use may be obtained from the Rights and Permissions editor.
ACSM National Center
401 West Michigan St., Indianapolis, IN 46202-3233.
Tel.: (317) 637-9200 Fax: (317) 634-7817
2010 American College of Sports Medicine.
ISSN # 1056-9677
PERSONAL TRAINING
A BROAD PROFESSION
By Julie Downing, Ph.D., FACSM
Health & Human Performance Department
Central Oregon Community College
The professional Personal Trainer performs
many different jobs when working with their
clients.
How do we know that the profession of Personal Training has such a broad list of job tasks?
We (the ACSM Personal Training Committee) took a very simple approach and recently surveyed
Personal Trainers about what their job entails and the importance/frequency of each task. This is
the second time we have conducted such a survey. Our first one was conducted in 2004 when
ACSM introduced its Personal Training certification. This time, we had nearly 2,100 survey respon-
dents and what we found was not necessarily surprising but instead confirmed what we strongly
suspected to be the case in the world of Personal Training Personal Trainers do it all. They are
involved in many different tasks in helping clients achieve goals and objectives.
Job Task Analysis Survey highlights illustrated that Personal Trainers:
work with all populations (provided that they have been medically cleared for exercise)
with a multitude of goals and require knowledge to modify exercise prescription/
assessment based on clients needs.
must possess knowledge of proper spotting techniques for various exercises.
coach/counsel clients and are using several different health behavior change models, as
well as motivational techniques.
require business/marketing knowledge in order to be successful.
must be able to communicate effectively in-person, on the phone, and electronically.
earn clients trust by ensuring safety and helping clients achieve their goals.
So with this valuable insight from the Job Task Analysis, our ACSM certification exam prepara-
tion materials, textbooks, and exam content will more closely reflect what todays trainer needs
to know. Our certification exam blueprint will now have the following four content domains (per-
centages shown are the proportion of the exam questions from each area):
I Initial Client Consultation & Assessment 26%
II Exercise Programming & Implementation 27%
III Exercise Leadership & Client Education 27%
IV Legal/Professional/Business/Marketing 20%
So in summary, the ACSM Personal Training Certification exam will include more content on:
behavior modification (found in domain III and goes beyond the six stages of change transtheoret-
ical model), strength training, spotting techniques, business/marketing, effective communication,
and finally working with special populations who have been medically cleared for exercise.
The ACSM s Resources for the Personal Trainer, 3rd Edition text is extremely helpful in
reviewing for the ACSM Personal Training Certification. For more information on ACSMs
Personal Training Certification, visit www.acsm.org/certification.
Thanks to all of you who helped us out by completing the recent Personal Trainer job task
analysis survey. We could not have done this valuable work without your feedback.
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ACSMS CERTIFIED NEWS JULYSEPTEMBER 2010 VOLUME 20:3 3
IT IS WELL DOCUMENTED AND
UNDERSTOOD THAT THE FIRST FOUR
TO SIX WEEKS OF ANY RESISTANCE
TRAINING PROGRAM INVOLVES
STIMULATING AND DEVELOPING
MOTOR PATHWAYS.
2
As fitness professionals, part of our job is to help facilitate the
development of these motor pathways by collecting the necessary
information through client assessment, evaluating this information,
and prescribing exercise that reflects this information.
Properly trained fitness professionals are well prepared and eager
to design exercise prescriptions based on a clients needs, goals,
health history, and initial fitness assessment. There does, however,
exist a need to examine the process by which fitness professionals go
about collecting this information. Testing protocols often become
routine practice, utilizing the same health related fitness assessments
for all clients as a starting point. This use of routine testing is due to
the validity and reliability of the assessments proven over time, which
is to be respected as these assessments provide information that
helps us when prescribing exercise. However, we need to evaluate
our assessment choices and offer a variety of ways to assess our
clients that would better represent the individuals needs beyond the
basic components of fitness. The ability to assess a clients motor
learning needs could certainly be part of this process.
In preparation of administering a fitness assessment and following
a review of a clients health history and exercise experience, a fitness
professional should ask themselves the following questions. What are
my options for testing the basic components of fitness? Does the facil-
ity provide the space, equipment and time to offer the client these
options? How do I offer those choices to my client? Is there anything
else that exists outside of the basic components of fitness that I can
offer a client as part of their initial assessment? Testing for a motor
learning skill that is specific to the needs of the client could possibly
be part of this assessment. This would be in addition to and not in
place of the testing of the basic components of fitness.
Motor Learning as a basis for fitness
assessment and program development
Most people possess a certain amount of basic motor skills. Day
to day motor abilities enable an individual to navigate their way
through the world. A basic skill such as brushing your teeth is so well
learned through childhood that the thought behind the act of brush-
ing is non-existent, except for the motivation to initiate the move-
ment. Therefore, motor learning is a part of persons natural growth
and internal processes that determine a persons ability to perform
motor skills well and with good technique.
7
Motor skills for athletic
performance, however, are very different and require an assessment
process that is planned and systematic.
The following are five important questions to review before begin-
ning a motor skills assessment:
6
1. Why assess?
2. What variables should I assess?
3. Which test will assess the most important variable?
4. How will you prepare the client for the assessment?
5. How will you utilize the results?
For example, a male client presents with a goal of improving his
tennis game. After a short conversation with this client, together you
establish that he would like to improve his return game from the
baseline. In addition to the basic components of fitness, you decide to
conduct a baseline speed and agility forehand and backhand test.
3
To
prepare your client you would describe the test and the procedures
leading up to the actual test. Provide a visual demonstration prior to
testing along with specific instructions regarding the testing proce-
dure and all beginning and ending parameters. Begin with a proper
warm-up, and following a proper cool-down period, share the results
of the assessment with your client. This would include relating your
clients performance to any norms generated from prior testing and
research, and then relate the results to future strategies for training.
6
There exists a plethora of tests related to motor performance.
Choosing the proper test requires a little research and the ability to
apply it to the needs and goals of the client. Fleishman and colleagues
4
have developed taxonomy of motor abilities with two main categories;
perceptual motor abilities and physical proficiency abilities. Some
examples of Fleishmans physical proficiency abilities include static
strength, dynamic strength and explosive strength. Some examples of
Fleishmans perceptual motor abilities would include response orienta-
tion and reaction time.
1,4
Using this taxonomy as a guide (see Table),
a fitness professional analyzing the clients needs should be able to
choose an ability that most closely relates to the clients need and con-
duct a test that will support that choice. It would be important to
HEALTH & FITNESS FEATURE
Fitness Assessment and Exercise Prescription:
BY DIERDRA BYCURA, Ed.D., ACSM HFS
AND THOMAS P. MAHADY, M.S., CSCS
ARE YOUR ASSESSMENTS PROVIDING
THE INFORMATION YOU NEED?
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4 ACSMS CERTIFIED NEWS JULYSEPTEMBER 2010 VOLUME 20:3
assess those physical abilities either in a generic fashion or by recreat-
ing the goal task as part of a pre/post type assessment.
Utilizing Fleishmans Taxonomy of Motor Abilities, the baseline
speed and agility drill cited above would be an example of recreating
a gross body coordination test that is task specific to the baseline play
that is common during a tennis match, whereas an example of a
generic test would be the timing of a client in the 40 yard dash.
When deriving assessments to measure particular abilities, it is neces-
sary to record the specifics of the assessment to maintain the reliabil-
ity of the post-test.
5
Conclusion
Knowing how the body works and best adapts to stimuli is vital to
the client/fitness professional relationship. Understanding the acqui-
sition of motor skills is an integral part of fitness professionals train-
ing skill. A fitness professional who can integrate these concepts into
his program assessment, exercise prescription and subsequent train-
ing will help facilitate the clients goals more effectively.
About the Authors
Dierdra Bycura, Ed.D., ACSM-HFS, CPT is an assis-
tant clinical professor at Northern Arizona
University in Flagstaff, Arizona. Dierdra also is a
member of the ACSM Exam Development Team for
credentialing and certification.
Thomas P. Mahady, M.S., CSCS is the senior exercise
physiologist for The Cardiac Prevention and
Rehabilitation Center at Hackensack University
Medical Center in Hackensack, NJ. He also is an
adjunct professor at William Paterson University in
Wayne, NJ.
References
1. Coker, CA. Motor Learning & Control, 2nd Ed. Scottsdale, AZ:
Holcomb Hathaway, 2009, pp. 16-17.
2. Essentials of Strength Training and Conditioning, 3rd Ed.
Baechle, TR, Earle, RW, editors. Champaign, IL: Human Kinetics,
2008., pp.94-96.
3. Etcheberry, P. Etcheberry certification for tennis. Available at:
http://etcheberryexperience.com/en/info/tennis_certification.
Accessed September 17th, 2010.
4. Fleishman, EA. Structure and measurement of psychomotor abili-
ties. In R.N. Singer (Ed.), The psychomotor domain: Movement
behavior. Philadelphia, PA: Lea & Febiger, 1972, pp. 78-106.
5. Magill, RA. Motor Learning & Control: concepts and applica-
tions, 9th Ed. New York, NY: McGraw-Hill, 2011, pp. 55-59.
6. Payne, V. G., and L.D. Isaacs. Human Motor Development: A
Lifespan Approach. Mountain View, Calif.: Mayfield, 1987, pp. 433-
435.
7. Schmidt, RA, Wrisberg, CA. Motor Learning and Performance: A
situation-based learning approach, 4th Ed., Champaign, IL: Human
Kinetics, 2008, pp. 11-12.
Table. Fleishmans Taxonomy of Motor Abilities
Abilities Definition Example
Control precision Highly controlled movement adjustments, especially those
involving larger muscle groups Dribbling a soccer ball
Multi-limb coordination Coordinate numerous limb movements simultaneously Volleyball spike
Response orientation Select a response rapidly from a number of alternatives,
as in choice reaction time situations Tail back trying to find an opening
Speed of limb movement Make gross rapid limb movement without regard for reaction time Hockey slap shot
Rate control Make continuous speed and direction adjustments with precision
when tracking Mountain biking
Manual dexterity Control manipulations of large objects using arms and hands Water polo
Finger dexterity Control manipulations of small objects primarily through the use of fingers Dialing a cell phone
Arm-hand steadiness Make precise arm-hand positioning movements where involvement
of strength and speed are minimal Dentistry
Wrist finger speed Move the wrist and fingers rapidly Blackjack dealing
Aiming Direct hand movements quickly and accurately at a small object in space Marksmanship
Physical Proficiency Abilities
Static strength Ability to generate maximum force against weighty external object Pushing car out of snow bank
Dynamic strength Muscular endurance or ability to exert force repeatedly Rock climbing
Explosive strength Muscular power or ability to create maximum effort by combining force
and velocity Throwing javelin
Trunk strength Dynamic strength of trunk muscles Pole vault
Extent flexibility Ability to move trunk and back muscles through large range of motion Circus contortionist
Dynamic flexibility Ability to make repeated, rapid flexing movements Diving, aerial ski jumping
Gross body coordination Ability to coordinate numerous movements simultaneously while the body
is in motion Slalom skiing, synchronized swimming
Gross body equilibrium Ability to maintain balance without visual cues Tightrope walking while blindfolded
Stamina Cardiovascular endurance or ability to sustain effort Climbing Everest
Information obtained from 1, 4.
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ACSMS CERTIFIED NEWS JULYSEPTEMBER 2010 VOLUME 20:3 5
Functional fitness has been defined as having the physical capacity
to perform activities of daily living in a safe and independent manner
without undue fatigue.
3
Some fitness professionals refer to this as
strength you can use. One of the most popular techniques touted to
improve functional fitness is the use of unstable surface training. Training
implements employed to induce instability include wobble boards, foam
rollers, stability balls, balance discs, and BOSU devices, among others.
According to proponents, training on an unstable surface imposes a
greater challenge to the neuromuscular system, thereby eliciting maxi-
mal improvements in human function. Indeed it has been shown that
unstable surfaces are valuable in rehabilitation settings, particularly in
helping to alleviate symptoms associated with lateral ankle sprains.
19, 15
There also is a substantial body of research showing that performing
abdominal and lumbar exercises on unstable implements increases activ-
ity of the core musculature compared to similar movements performed
on a stable surface.
17, 4, 16, 6
And there is some evidence that training in an
unstable environment may help to improve proprioception in the lower
body musculature,
11, 8
potentially by enhancing sensory perception.
Whether these enhancements translate into better performance of
activities of daily living, however, is open for debate.
A problem with the practical application of unstable surface training
is that it often fails to take into account the concept of specificity. The
Specific Adaptation to Imposed Demands (SAID) principle dictates
that optimal transfer of the exercise benefit is achieved when move-
ments most closely match those of a given task. Considering that the
vast majority of everyday activities are carried out in a stable environ-
ment, it therefore follows that functional transfer will be optimized by
training on stable surfaces. This is consistent with research by Yaggie and
Campbell,
20
who found that although training on a BOSU

ball improved
subjects ability to stand quietly, it failed to improve functional markers
of strength, balance, and power.
Moreover, it is important to note that people commonly lose func-
tional ability due to a loss of muscle tissue and thus an associated loss of
strength.
13, 7, 10
Accordingly, improving muscle hypertrophy and strength
will result in substantial improvements in functional ability. In a study by
Fiatarone et al.,
7
six women and four men (mean age = 90 1 years)
were recruited from a nursing home population to evaluate the effects
of strength training on functional capability. Subjects trained three days
a week, performing three sets of eight repetitions on a machine leg
extension apparatus. After eight weeks, subjects increased their lower
body strength by 175% and their functional scores on a test of walking
and balance improved by approximately 48%. Two of the participants
were actually able to walk without the assistance of their canes! These
improvements in function were attained by training solely on a resist-
ance machine an implement that functional training proponents often
dismiss as developing non-functional strength.
Alternatively, unstable surface training has been found to be subopti-
mal for increasing strength. Behm, et al.
2
studied the EMG response to
exercise when training on both stable and unstable surfaces. Eight phys-
ically active males performed maximal voluntary contractions of the
knee extensors and plantar flexors while either seated in a chair (stable
surface) or on a Swiss ball (unstable surface). Results showed that train-
ing on the unstable surface resulted in a 44% reduction in muscle activ-
ity and a 70% decrease in force output compared to the same activities
performed on the stable surface. Similar findings have been reported in
many other studies, with results holding true in the performance of both
upper body and lower body exercises.
18, 9, 14, 1
A decrease in muscle force
output during training mitigates increases in muscular strength, which
would seemingly attenuate functional transfer.
Further, the functional benefits of unstable surface training also may
be limited in athletic populations. Cressey et al.
5
investigated the use of
unstable surface training on athletic performance in elite athletes.
Nineteen recruits (ages 18 to 23 years) from a National Collegiate
Athletic Association Division I college soccer team were randomly divid-
ed into one of two groups, where ten subjects supplemented their usual
exercise program by performing various lower body exercises on inflat-
able rubber discs while the nine others performed the same exercises
on a stable surface. Performance was assessed by a variety of tests
including the bounce drop jump, countermovement jump, 40- and 10-
yard sprint times, and T-test. After 10 weeks, the stable surface group
displayed greater performance improvements in all measures studied
compared to the unstable surface group, leading the authors to con-
clude that use of unstable surfaces may not be optimal for athletic per-
formance improvements in healthy, trained individuals. It was surmised
that diminished results in the unstable surface group may be due to a
reprogramming of neuromuscular patterns that chronically impairs
stretch-shortening cycle function essential for the performance of sport-
ing activities.
In conclusion, commonly accepted training tenets need to be reex-
amined with respect to the concept of functional fitness. Central to the
design of any fitness program is the principle of specificity, where exer-
cise routines are matched to an individuals needs, abilities, and goals.
Based on available research, it would seem that functional improvements
are best achieved when a majority of training is carried out on stable sur-
faces. In certain circumstances, it is possible that the addition of unstable
surface exercises to a routine may provide a synergistic benefit to func-
IS FUNCTIONAL TRAINING
REALLY FUNCTIONAL?
BY BRAD SCHOENFELD, M.S., CSCS
WELLNESS ARTICLE
The term "functional training" has become a
popular buzzword in the fitness field so
much so that several leading fitness
organizations now call it one of the biggest
current industry trends. The question is, does
the concept live up to the hype?
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6 ACSMS CERTIFIED NEWS JULYSEPTEMBER 2010 VOLUME 20:3
tional capacity. McKeon et al.
12
posited that a combination of approxi-
mately 75% stable and 25% unstable surface training may be ideal for
optimizing static and dynamic balance. Further research is warranted to
shed more light on this topic.
Moreover, it can be misleading to refer to exercise as either func-
tional or non-functional because functional transfer from training
exists on a continuum. For those who are very unfit, a routine using only
machines may be all that is required to sufficiently improve an individuals
ability to carry out desired activities of daily living. As fitness levels
improve and/or functional demands increase, exercises that challenge
the body in three-dimensional space will be necessary to realize greater
performance enhancements.
About the Author
Brad Schoenfeld, MS, CSCS, is the president of
Global Fitness Services in Scarsdale, NY. He is an
adjunct professor at Lehman College in the
Department of Health Sciences, and serves as an asso-
ciate editor for the NSCAs Strength and
Conditioning Journal.
References
1. Anderson KG, Behm DG. (2004). Maintenance of EMG activity and
loss of force output with instability. Journal of Strength and
Conditioning Research, 18(3): 637-40.
2. Behm, D.G., Anderson, K., and Curnew, R.S. (2002). Muscle force
and activation under stable and unstable conditions. Journal of
Strength and Conditioning Research, 16: 416-422.
3. Collins K, Rooney BL, Smalley KJ, Havens S. (2004). Functional fit-
ness, disease and independence in community-dwelling older adults
in western Wisconsin. Wisconsin Medical Journal, 103(1): 42-8.
4. Cosio-Lima, L.M., Reynolds, K.L., Winter, C., Paolone, V., and Jones,
M.T. (2003). Effects of physioball and conventional floor exercises
on early phase adaptations in back and abdominal core stability and
balance in women. Journal of Strength and Conditioning
Research. 17(4): 721-725.
5. Cressey EM, West CA, Tiberio DP, Kraemer WJ, Maresh CM. (2007).
The effects of ten weeks of lower-body unstable surface training on
markers of athletic performance. Journal of Strength and
Conditioning Research, 21(2): 561-7.
6. Duncan M. (2009). Muscle activity of the upper and lower rectus
abdominis during exercises performed on and off a Swiss ball.
Journal of Bodywork and Movement Therapies,13(4):364-7.
7. Fiatarone MA, Marks EC, Ryan ND, Meredith CN, Lipsitz LA, Evans
WJ. (1990). High-intensity strength training in nonagenarians.
Effects on skeletal muscle. JAMA, 13;263(22): 3029-34.
8. Hoffman, M. and Payne, V.G. (1995). The effects of proprioceptive
ankle disk training on healthy subjects. JOSPT. 21(2): 90-93.
9. Kohler JM, Flanagan SP, Whiting WC. (2010). Muscle activation
patterns while lifting stable and unstable loads on stable and unsta-
ble surfaces. Journal of Strength and Conditioning Research,
24(2): 313-21.
10. Lord SR, Ward JA, Williams P, Anstey KJ. (1994). Physiological fac-
tors associated with falls in older community-dwelling women.
Journal of the American Geriatric Society, 42(10), 1110-7.
11. Mattacola, C.G. and Lloyd, J.W. (1997). Effects of a 6-week strength
and proprioception training program on measures of dynamic bal-
ance: a single-case design. Journal of Athletic Training, 32(2): 128-
135.
12. McKeon, P.O. et al. (2008). Balance training improves function and
postural control in those with chronic ankle instability. Medicine
and Science in Sports and Exercise, 40(10): 1810-1819.
13. Melton LJ 3rd, Khosla S, Crowson CS, OConnor MK, OFallon
WM, Riggs BL. (2000). Epidemiology of sarcopenia. Journal of the
American Geriatric Society, 48(6), 625-30.
14. Nuzzo JL, McCaulley GO, Cormie P, Cavill MJ, McBride JM. (2008).
Trunk muscle activity during stability ball and free weight exercises.
Journal of Strength and Conditioning Research. 22(1): 95-102
15. Osborne MD, Chou LS, Laskowski ER, Smith J, Kaufman KR. (2001).
The effect of ankle disk training on muscle reaction time in subjects
with a history of ankle sprain. American Journal of Sports
Medicine, 29: 627632.
16. Sternlicht E, Rugg S, Fujii LL, Tomomitsu KF, Seki MM. (2007).
Electromyographic comparison of a stability ball crunch with a tra-
ditional crunch. Journal of Strength and Conditioning Research.
21(2): 506-9.
17. Vera-Garcia FJ, Grenier SG, McGill SM. (2000). Abdominal muscle
response during curl-ups on both stable and labile surfaces. Physical
Therapy, 80(6): 564-9.
18. Wahl MJ, Behm DG. (2008). Not all instability training devices
enhance muscle activation in highly resistance-trained individuals.
Journal of Strength and Conditioning Research. 22(4): 1360-70.
19. Wester JU, Jespersen SM, Nielsen KD, Neumann L. (1996). Wobble
board training after partial sprains of the lateral ligaments of the
ankle: a prospective randomized study. JOSPT, 23: 332336
20. Yaggie, J.A. and Campbell, B.M. (2006). Effects of balance training
on selected skills. Journal of Strength and Conditioning Research.
20(2): 422-428.
Editors Note regarding the Wellness Article,
Piriformis Syndrome: A Real Pain in the Butt
in the AprilJune 2010 issue of ACSMs Certified News
Several figures in the article show the hip being placed in external rotation.
The piriformis muscle is an external rotator and weak abductor of the femur
at the hip joint and internal hip rotation is an important component of a pir-
iformis stretch. Shortening of the piriformis muscle may limit internal rotation.
They might experience discomfort during and/or a difficulty achieving much
femoral internal rotation. As an alternative to internally rotating the femur,
the benefits of femoral internal rotation can be achieved by rotating the trunk
ipsilaterally (to the same side) and by flexing the trunk slightly (in a support-
ed manner). Piriformis stretches are often performed in conjunction with
stretches for the gluteus maximus, hamstrings, and iliotibial band because of
their collective effects on hip joint motion and stability. A supine piriformis
knee-hug stretch can become a gluteus maximus stretch by eliminating the
femoral internal rotation.
Knee should be pulled
gently toward
contralateral shoulder
(opposite) to initiate
femoral internal
rotation and to
stretch the piriformis.
Seated piriformis stretch
(notice slight adduction
and internal rotation).
THE CO-EDITORS OF ACSM S
CERTIFIED NEWS WOULD LIKE TO
THANK PETER RONAI, MANAGER
OF COMMUNITY HEALTH FOR
AHLBIN REHABILITATION CENTERS
IN BRIDGEPORT, CT AND DR. RUSTY
SMITH, CHAIR OF THE DEPARTMENT
OF CLINICAL AND APPLIED
MOVEMENT SCIENCES IN THE
BROOKS COLLEGE OF HEALTH AT
THE UNIVERSITY OF NORTH
FLORIDA FOR PROVIDING THIS
ERRATUM.
Another alternative.
Notice slight adduc-
tion and internal rota-
tion. The quadriped
position might not be
well tolerated by or
appropriate for all
clients.
This is technically
stretching the piri-
formis too.
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ACSMS CERTIFIED NEWS JULYSEPTEMBER 2010 VOLUME 20:3 7
BY JANET P. WALLACE, Ph.D., FACSM
AND BLAIR JOHNSON, M.S.
CLINICAL FEATURE
The endothelium, the single most inner layer of the artery, is the
site of origin for atherosclerosis development. The endothelial pro-
duction of nitric oxide (NO) is how the endothelium protects the
artery from atherosclerosis. Nitric oxide controls the antiatherogenic
activities of platelet aggregation, coagulation, adhesion, fibrinolysis,
and vascular tone in the artery. The left panel of Figure 1 illustrates
NO synthesis and function. The synthesis of NO from L-arginine, oxy-
gen, and electrons carried by nicotinamide adenine dinucleotide phos-
phate (NADPH) is catalyzed by endothelial nitric oxide synthase
(eNOS), and dependent on other cofactors. Endothelial nitric oxide
synthase can be activated by shear stress from arterial blood flow,
insulin, and acetylcholine (ACh). Insulins stimulation of eNOS and
subsequent NO production is dependent on insulin sensitivity, which
could be a mechanism of why patients with diabetes are at higher risk
for cardiovascular diseases.
10
The right panel of Figure 1 illustrates how the NO role in protect-
ing the endothelium is compromised in oxidative stress. Superoxide
radicals (O
2
-
) can accumulate as a result of excess oxidative stress.
Nitric oxide is used up as an antioxidant scavenger of O
2
-
. The reac-
tion between O
2
-
and NO not only contributes to loss of NO avail-
able for the antiatherogenic functions of the endothelium, but it also
results in formation of peroxynitrite (ONOO
-
), itself a potent oxi-
dant. Furthermore, O
2
-
and ONOO
-
oxidize a cofactor necessary for
normal production of NO by eNOS, which leads to loss of eNOS
functioning. This dysfunctional eNOS produces O
2
-
instead of NO,
thus resulting in a vicious cycle of more oxidative stress. Taken togeth-
er, oxidative stress results in what we call reduced NO bioavailability
which compromises all the protective functions of the endothelium.
Among the sources of oxidative stress for any individual is a high-
fat meal.
6
A high-sugar meal also is a direct source of oxidative stress
for patients with diabetes. Atherosclerotic cardiovascular disease was
proposed to be a meal-related (postprandial) phenomenon as early as
1979 and has grown in acceptance, more so in other countries. In fact,
postprandial lipemia (fat in the blood) is now been considered an inde-
pendent risk factor for atherosclerotic cardiovascular disease.
4
The
average diet of a healthy North American man consists of approxi-
mately 50 to 100 g of fat per day, consumed during three to six eat-
ing events. Depending on the size and composition of the meal, the
postprandial lipemic response can last up to eight hours, and therefore
the typical North American diet results in continuous exposure to
postprandial lipemia. As illustrated in Figure 2, each exposure increas-
es the lipemia. When cells utilize the fats oxidative stress results, lead-
ing to endothelial dysfunction. The NO mediated protective mecha-
nisms for the endothelium are compromised as illustrated in Figure 1
(right panel) causing endothelial dysfunction. Sedentary and over-
weight adults tend to have higher fat intake, exacerbating this athero-
sclerotic oxidative cycle by pro-
longing and magnifying the
adverse absorptive state.
Consecutive high-fat meals pro-
duce greater endothelial dysfunc-
tion and higher oxidative stress
for each consecutive meal. Thus,
recurring postprandial oxidative
stress initiates a nearly continuous
cycle of endothelial dysfunction.
The classic study by Vogel and
colleagues reported a decline in
endothelial function following a
high-fat meal in 10 healthy adults
in 1997.
7
Figure 3 illustrates the
endothelial response to high-fat
and low-fat meals. The low fat
Figure 1. Left Panel: Normal protective functions of nitric oxide (NO). Right Panel:
Oxidative stress compromises the protective functions of NO to create the environ-
ment for the etiology of atherosclerosis
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How many times have you heard that only 50% of the
patients who have a cardiac event have elevated choles-
terol or that only 50% of the people with elevated cho-
lesterol develop heart disease? These types of incon-
stancies have led medical research to find other etiolo-
gies for atherosclerosis. More recently you have proba-
bly heard of the inflammation etiology. Inflammation has
always been implicated in atherosclerosis even when the
Response to Injury Hypothesis was the dominant theo-
ry. What is down played in both theories, however, is
the source of the inflammation. After all, the immune
system needs to respond to an allergen or irritant of
some kind. What initiates the immune response that
leads to heart disease or stroke?
NEW THOUGHTS
ON WHAT REALLY
CAUSES HEART DISEASE
AND HOW EXERCISE
HELPS BEYOND
TRADITIONAL RISK
FACTORS
CNews20.final:ACSM template 10/26/10 9:09 AM Page 7
8 ACSMS CERTIFIED NEWS JULYSEPTEMBER 2010 VOLUME 20:3
meal had no effect on the
endothelium (blue line),
whereas the high-fat meal
exhibited a decline in function
throughout the postprandial
period (red line). The lowest
point in endothelial function is
at four hours following the
meal, returning to baseline at
six hours. The decline in
endothelial function was in
response to the increase in
triglycerides (lipids). Later
research found the increase in
triglycerides increased oxida-
tive stress. Thus, the lipemic
load produced the oxidative
stress which resulted in endothelial dysfunction.
In a recent review article,
9
we found that approximately 45% of
calories from fat is the minimum amount of fat that causes endothe-
lial dysfunction; which also is contingent on the type of fat consumed.
Most saturated fats, including monounsaturated fats, are capable of
impairing endothelial function. Transfats and foods cooked in re-used
deep-frying oil generate even further damage to the endothelium.
However, polyunsaturated fats have been found not impair endothe-
lial function.
How can we prevent the consequences
of a high-fat meal?
Interventions targeting a lower lipemic load or oxidative stress
have been designed to counteract the consequences of a high-fat
meal. Lipemic load has been managed through the use of insulin and
exercise, whereas oxidative stress has been manipulated with statins,
exercise, and diet, including antioxidant vitamins, or supplementation.
In exercise interventions, the exercise stimulus has been either
one single exercise session or the effects of training/detraining. We
repeated the classic study by Vogel and colleagues, but added a 40
minute session of treadmill walking two hours after the high-fat meal.
3
As illustrated in Figure 4, we found that the exercise not only coun-
teracted the decline in endothelial function, but improved it. Then we
observed how active and inactive adults responded to the high-fat
meal and found the active adults had no decrease in endothelial func-
tion at four hours after the meal, whereas the inactive adults
decreased 31%. See Figure 5. We also found the active adults to have
a lower triglyceride response, lower oxidative stress response, and
higher antioxidant response to the high-fat meal.
Exercise has several ways of affecting endothelial function.
Exercise can act through an improvement in insulin sensitivity,
decrease in postprandial lipemia, increase in NO,
2
and/or an increase
in antioxidant defense. A single session of most types of exercise,
including resistance exercise is sufficient to increase insulin sensitivity,
in healthy, obese, and type 2 diabetic adults. Similarly, exercise train-
ing improves insulin sensitivity regardless of age, in healthy, obese, and
type 2 diabetic adults; even with no change in
.
VO
2
max. Changes in
insulin sensitivity associated with exercise vanish within three to five
days; and can be regained after a single exercise session.
1
Dynamic exercise (acute or chronic) causes a significant, moder-
ately large decrease in postprandial lipemia. There appears to be no
influence of exercise intensity, duration, or time between exercise
and the meal on the attenuation of postprandial lipemia. The
sequence of the exercise, before or after the meal, does not affect
the decrease in postprandial lipemia. Even the accumulation of inter-
mittent physical activity throughout a single day is as effective in
Figure 3. The classic response of the endothelium to
a high-fat meal (red). The lowest point of function is
four hours following the meal. (figure adapted from
Vogel et al (Vogel, Corretti et al. 1997))
Figure 4. The typical response to a high-fat meal
(red) is counteracted by exercise (blue). (figure
adapted from Padilla et al(Padilla, Harris et al. 2006))
Figure 5. Exercise appears to counteract the harmful
effects of a high-fat meal by reducing the lipid load
and oxidative stress in addition to increasing
antioxidant defense.
New Thoughts (continued on page 11)
Figure 2. The events
leading to endothelial
dysfunction and
atherosclerosis.
CNews20.final:ACSM template 10/26/10 9:09 AM Page 8
ACSMS CERTIFIED NEWS JULYSEPTEMBER 2010 VOLUME 20:3 9
IN HEALTH CARE, EXPERTS ARE
TYPICALLY IN THE DRIVERS SEAT
WHEN IT COMES TO PATIENT CARE. AS
WELLNESS COACHES, WE ARE KEENLY
AWARE THAT THIS APPROACH IS NOT
EFFECTIVE IN FOSTERING LONG-
LASTING BEHAVIORIAL CHANGE. FOR
CLIENTS TO THRIVE AND ACHIEVE
OPTIMAL HEALTH AND WELL BEING,
THEY MUST GET INTO THE DRIVERS
SEAT, BOTH IN COACHING SESSIONS
AND, ULTIMATELY, IN LIFE.
Why Take the Wheel?
According to proponents of the self-
determination theory, navigating from
behind the wheel is the most natural place
for humans. We are self-determining beings,
innately inclined towards psychological
growth and development. We are happiest
and most productive when we are in control
of our lives. Richard M. Ryan, Ph.D., and
Edward L. Deci, Ph.D., (2000) at the
University of Rochester write, The fullest
representations of humanity show people to
be curious, vital, and self-motivated. At their
best, they are agentic and inspired, striving to
learn; extend themselves; master new skills;
and apply their talents responsibly. That
most people show considerable effort,
agency, and commitment in their lives
appears, in fact, to be more normative than
exceptional, suggesting some very positive
and persistent features of human nature
(p. 68).
2
Please Drive Me
Yet many of our clients surrender the
wheel to others, causing them to become
stuck, unable to move toward their desired
destination. They take what appears be to an
attractive but unproductive detour, seeing it
as the easy way out, avoiding responsibility
for the direction of their own lives. Some
choose to ride in the passenger seat, while,
even worse, some sit in the back seat.
Veering off course, they are no longer true
to their own internal compass, and soon feel
lost and discouraged.
It is not difficult for coaches to differenti-
ate between the drivers and the passengers.
We have all seen clients who readily comply,
doing what others say is good for them, such
as taking their medications or eating broc-
coli. Others defy by resisting a request or
advice. Either way, these clients are not act-
ing autonomously. A coach will often hear:
My doctor is in charge, my genes are in
charge, the experts and their prescriptions
are in charge, my wife makes the health deci-
sions, my job is in charge. When other peo-
ple or external forces are in the drivers seat,
failure is ultimately likely, especially for those
who are trying to lose weight, get fit, or
adopt any new habit. The best way for our
clients to achieve their goals is to help them
take their rightful place behind the wheel.
We must encourage them to tap into self-
motivation, which according to Deci and
Ryan, is at the heart of creativity, responsi-
bility, healthy behavior, and lasting change
(p. 9).
1
Our Core Drives
Deci and Ryans theory of human motiva-
tion asserts that human thriving results from
satisfying three motivational drives: the
desire to be autonomous (making choices
that are true to ones core, not imposed by
others or ones inner critic); to be competent
(using ones strengths, becoming skilled in life
tasks); and to be connected (doing things
that support others). These core drives are
alive in our clients when it comes to taking
good care of their mental and physical health.
As coaches, it is our job to help our clients
recognize, enliven, and strengthen them.
Coaxing Clients into the
Drivers Seat
We can learn valuable lessons from the
work of Deci and Ryan. First, it is important
to acknowledge that, even as coaches, we
are not able to motivate our clients. We can
only create the conditions in which they will
motivate themselves. Fostering choice will
increase our clients intrinsic motivation.
Taking our clients perspective not our own,
we must encourage our clients to initiate,
experiment, and assume responsibility. We
must be willing to set limits while still sup-
porting our clients autonomy helping
them discern where their rights end and the
rights of others begin, while making sure the
limits are as wide as possible and allow for
choice. In addition, we must help them
recruit sources of autonomy support outside
the session. We also must be attuned to facil-
itating feelings of competence, which are cru-
cial for intrinsic motivation.
Look, Im Driving!
According to Deci and Ryan, humans
have an innate need to feel competent. Yet,
we may be driven by a negative belief we
have constructed about ourselves and be
swayed by our inner critic: I am a loser or a
failure or inadequate because I cannot lose
weight, stay on a fitness routine, meditate
longer than a few nanoseconds, or avoid
doughnuts when they are put on a plate in
front of me. To combat feelings of inadequa-
cy, our clients must be encouraged to be
proactive, taking on optimally challenging
tasks with our enthusiastic support.
Cheering on our clients to success, we
enable them to feel competent, energized,
and motivated. According to Deci and Ryan,
feelings of competence are crucial and, when
accompanied by autonomy, lead to increasing
accomplishment and learning throughout life.
Conclusion
If our clients are to achieve optimal health
and well being, they must take charge of the
wheel, figuring out what works for them as
unique individuals so that it becomes part of
who they are and non-negotiable. Coaches
should encourage clients to act as though
they are in the drivers seat to be the boss
who solicits advice from the experts, then
experiments, reflects, adjusts, and experi-
ments again to arrive ultimately at the best
COACHING NEWS:
WHOS IN THE DRIVERS SEAT?
Coaching News (continued on page 13)
By Margaret Moore (Coach Meg), MBA
CNews20.final:ACSM template 10/26/10 9:09 AM Page 9
10 ACSMS CERTIFIED NEWS JULYSEPTEMBER 2010 VOLUME 20:3
While 8 to 12 exercise repetitions is a generally accepted guide-
line for beginning trainees, most fitness professionals have heard that
muscle strength is best developed by training with lower repetitions
(e.g., 4 to 8 reps per set), muscle hypertrophy is best developed by
training with moderate repetitions (e. g. , 8 to 12 reps per set), and
muscle endurance is best developed by training with higher repeti-
tions (e. g. , 12 to 16 reps per set),). However, the 2006 ACSM
guidelines for resistance exercise prescription state that Thus, for
any common range of repetitions (3 to 6, 6 to 10, 10 to 12, etc.)
there is little evidence to suggest a specific number of repetitions will
provide a superior response relative to muscular strength, hypertro-
phy, or absolute muscular endurance (page 156).
1
These guidelines
recommend that strength training participants choose a range of
repetitions between 3 and 20 (e.g., 3 to 5, 8 to 10, 12 to 15) that can
be performed at a moderate repetition duration (page 158).
1
One study that compared low-repetition and moderate-repetition
training was conducted by Chestnut and Docherty
5
with previously
untrained young men (mean age 24 years). The low repetition group
performed 6 sets of 4 repetitions each, and the moderate repetition
group performed 3 sets of 10 repetitions each. This volume-equated
training protocol was practiced three days a week for a period of ten
weeks. At the conclusion of the training program, both the low-rep-
etition exercisers and the moderate-repetition exercisers experi-
enced similar increases in muscle strength and muscle cross-sectional
area, indicating similar effects on muscle strength and muscle hyper-
trophy from both exercise protocols in previously untrained young
men.
A study by Bemben and others
4
examined the effects of moder-
ate-repetition and high-repetition training on muscle strength and size
in previously sedentary women between 41 and 60 years of age. The
moderate-repetition trainees performed 8 repetitions per set and the
high-repetition trainees performed 16 repetitions per set. Both exer-
cise groups trained three days a week for a period of six months. At
the conclusion of the training program, both the moderate-repetition
exercisers and the high-repetition exercisers attained similar improve-
ments in muscle strength and muscle cross sectional area, suggesting
similar effects on muscle strength and muscle hypertrophy from both
exercise protocols in previously untrained middle-aged women.
Behm and colleagues
3
incorporated a different approach to exam-
ine the muscle activation response to low, medium, and high-repeti-
tion resistance training. Using electromyograph (EMG) technology,
these researchers monitored 14 trained young men (mean age 21
years) as they performed five repetitions with their five-repetition
maximum resistance, 10 repetitions with their 10-repetiton maximum
resistance, and 20 repetitions with their 20-repetition maximum
resistance. The results revealed no significant differences in muscle
inactivation, strength loss, or antagonist/agonist EMG activity
whether training to muscle fatigue with 5, 10, or 20 repetitions.
These findings indicated that trained young men experience similar
muscle responses to low, medium, and high-repetition strength exer-
cise that terminates in tissue fatigue.
A 2009 study by Wilborn and others
6
investigated the effects of
moderate-repetition and high-repetition training on several key regu-
lators of muscle development and hypertrophy. The subjects were 13
previously untrained young men (mean age 21.5 years) who per-
formed two strength training sessions separated by two weeks, serv-
ing as their own controls in a cross-over research design. During one
session the participants performed four sets of 18 to 20 repetitions
with 60% to 65% of their maximum resistance, and during the other
session they performed four sets of eight to 10 repetitions with 80
to 85% of their maximum resistance. After each exercise session,
muscle biopsies were obtained (at four time periods) to assess
changes in gene expression and myogenic activity. Both exercise pro-
tocols produced the same effects with respect to the expression of
various genes that are involved in muscle hypertrophy. The
researchers concluded that strength exercise between 60% to 85%
of maximum resistance (8 to 20 repetitions) is effective for eliciting
significant changes in the hypertrophic and myogenic regulators asso-
ciated with training-induced muscle development.
Based on the result of these repetition studies, it would seem that
training to muscle fatigue with sets of 4 to 20 repetitions is effective
for increasing muscle strength and hypertrophy, with no significant dif-
ferences among low, moderate and high-repetition exercise protocols.
These findings seem to support the 2006 ACSM
1
resistance training
statement that a range of 3 to 20 repetitions per set may be effective
for enhancing muscle strength and size.
1
The number of repetitions performed with a given percentage of
maximum resistance may differ due to muscle fiber composition
(ratio of Type 1 and Type 2 muscle fibers), which varies among indi-
viduals and muscle groups, and changes with age. However, it would
BY WAYNE L. WESTCOTT, Ph.D.
Both the 2006
1
and 2010
2
American College of Sports Medicines Guidelines f or Exercise
Testing and Prescription recommend a standard strength training protocol that involves eight
to 12 repetitions with an appropriate resistance. Of course, there is an inverse relationship
between the exercise resistance and the number of repetitions that can be completed.
Although there is considerable variability among individuals and muscle groups, 8 to 12
repetitions can typically be completed with approximately 75% of maximum resistance.
RESULTS
RESISTANCE, REPETITIONS AND
HEALTH & FITNESS COLUMN
CNews20.final:ACSM template 10/26/10 9:09 AM Page 10
ACSMS CERTIFIED NEWS JULYSEPTEMBER 2010 VOLUME 20:3 11
appear that for most people, improvements in muscle strength, size,
and endurance may be attained with a range of repetitions, as long as
the exercise set is continued to muscle fatigue. That is, the key to mus-
cle development seems to be high-effort resistance exercise that
fatigues the target muscles within the anaerobic energy system. From
a practical perspective, the application of this information may render
strength training a more interesting activity through greater variation
of exercise protocols and progressions.
About the Author
Wayne L. Westcott, Ph.D., teaches exercise science and conducts fitness
research at Quincy College in Quincy, MA.
References
1. American College of Sports Medicine (7th edi-
tion). ACSMs Guidelines For Exercise Testing
and Prescription. Philadelphia: Lippincott,
Williams and Wilkins, 2006. pp. 156-158.
2. American College of Sports Medicine. ACSMs
Guidelines For Exercise Testing and Prescription
(8th edition). Philadelphia: Lippincott, Williams
and Wilkins, 2010. p 172.
3. Behm, D. G., G. Reardon, J. Fitzgerald, and E. Drinkwater. The effect
of 5, 10, and 20 repetition maximums on the recovery of voluntary
and evoked contractile properties. Journal of Strength and
Conditioning Research, 16(2): 209-218, 2002.
4. Bemben, D. A., N.L. Fetters, M.G. Bemben, et al. Musculoskeletal
response to high and low intensity resistance training in early post-
menopausal women. Medicine and Science in Sports and Exercise,
32(11): 1949-1957, 2000.
5. Chestnut, J. L.., and D. Docherty. The effects of 4 and 10 repetition
maximum weight training protocols on neuromuscular adaptations in
untrained men. Journal of Strength and Conditioning Research, 13:
353-359, 1999.
6. Wilborn, C. D., L. W. Taylor, M. Greenwood, et al. Effects of differ-
ent intensities of resistance exercise on regulators of myogenesis.
Journal of Strength and Conditioning Research, 23(8): 2179-2187,
2009.
reducing postprandial lipemic load as one session of continuous exer-
cise. The exercise-induced reduction in postprandial lipemia also is
independent of the metabolic substrate utilized during exercise.
5
Oxygen uptake, essential to sustained physical activity, produces
reactive oxygen species crucial for energy production; often resulting
in oxidative stress, depending on exercise intensity and training. High-
intensity physical activity produces greater oxidative stress; whereas
trained populations exhibit less oxidative stress due to higher antiox-
idant defense to a given intensity. More recently, exercise-induced
oxidative stress has been considered to have a beneficial impact
rather than compromise health. A major benefit of moderate intensi-
ty exercise is to induce a moderate oxidative stress which stimulates
expression of antioxidant enzymes.
8
Summary
The postprandial period creates a harmful environment in the
endothelium leading to atherosclerotic cardiovascular disease, includ-
ing heart attack, stroke and claudication. We have always known
exercise to have a role in the prevention and treatment of these dis-
eases, but the role of exercise may not be simply reducing risk factors
like high cholesterol or high blood pressure. Exercise may act best
through reducing postprandial lipid load, improving insulin sensitivity,
increasing antioxidant defense and/or increasing nitric oxide. Perhaps
we should broaden our perspective in our approach to prevent or
treat atherosclerotic cardiovascular disease through the classic risk
factors.
About the Authors
Janet P. Wallace, Ph.D., FACSM, has been involved
in ACSM certification since 1975 when she partici-
pated in the first ACSM Exercise Specialist
Workshop and earned ES certification #19. She
served on the CCRB from 1981-1994 and 2000-
2009. She also served on the ACSM Board of
Trustees from 1994-1997 and the Committee on the
Accreditation of the Exercise Sciences from 2003-
2006. After creating and operating one of the
most recognized clinical programs at Indiana University (1986-2005),
she is now leading an endothelial function research group. Please visit
her research at: http://www.iub.edu/~afp/research.html.
Blair Johnson, M.S., is currently pursuing a doc-
torate in exercise physiology at Indiana University.
His focus is on postprandial endothelial function
and how various blood flow patterns affect
endothelial function. In 2007, he received his
Master of Science degree from the University of
Wisconsin-La Crosse in Human Performance after
working as a research associate for the Cooper
Institute. He has been an ACSM member since 2001.
References
1. Eriksson, J., S. Taimela, et al. (1997). "Exercise and the metabolic syn-
drome." Diabetologia 40: 125-135.
2. Maeda, S., T. Miyauchi, et al. (2001). "Effects of training of 8 weeks
and detraining on plasma levels of endothelium-derived factors,
endothelin-1, and nitric oxide, in yount healthy humans." Life
Sciences 69: 1005-1016.
3. Padilla, J., R. A. Harris, et al. (2006). "The effect of acute exercise on
endothelial function following a high-fat meal." European Journal
of Applied Physiology 98: 256-262.
4. Patsch, W., H. Esterbauer, et al. (2000). "Postprandial lipemia and
coronary risk." Current Atherosclerosis Reports 2: 232-242.
5. Petitt, D. S. and K. J. Cureton (2003). "Effects of prior exercise on
postprandial lipemia: A quatitative review." Metabolism 52: 418-424.
6. Sies, H., W. Stahl, et al. (2005). "Nutritional, dietary and postprandi-
al oxidative stress." Journal of Nutrition 135: 969-972.
7. Vogel, R. A., M. C. Corretti, et al. (1997). "Effect of a single high-fat
meal on endothelial function in healthy subjects." American Journal
of Cardiology 79: 350-354.
8. Vollard, N. J. B., J. P. Shearman, et al. (2005). "Exercise-induced oxida-
tive stress: Myths, realities and physiological relevance." Sports
Medicine 35: 1045-1062.
9. Wallace, J. P., B. D. Johnson, et al. (2010). "Postprandial lipemia,
oxidative stress, and endothelial function: A review." International
Journal of Clinical Practice 64: 398-403.
10. Wheatcroft, S. B., I. L. Williams, et al. (2003). "Pathophysiological
implications of insulin resistance on vascular endothelial func-
tion." Diabetic Medicine 20: 255-268.
New thoughts continued from page 8
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12 ACSMS CERTIFIED NEWS JULYSEPTEMBER 2010 VOLUME 20:3
Individuals with PAD are typically over age 50, many have diabetes,
many are current or former smokers, and the disease can have pro-
found affects on the ability to ambulate. The prevalence of PAD, as with
most chronic diseases, is anticipated to increase over the next two
decades in conjunction with the aging of the population. PAD often goes
undetected because many patients do not recognize symptoms. This
emphasizes the need for appropriate clinical and community based
screening for PAD. Unfortunately in both diagnosed and undiagnosed
patients, and in those who are not treated appropriately, PAD can pro-
foundly affect quality of life. And importantly, those with PAD are at an
increased risk for developing cardiovascular disease, chronic angina, and
have a reduced life expectancy.
5
These persons also typically self-impose
an increasingly sedentary lifestyle as a method to remain asymptomatic.
This in turn increases health risks associated with inactivity.
Standard treatments for symptomatic PAD include medication
(Pletal and antiplatelets), revascularization (percutaneous angioplasty or
bypass), and exercise training. Although each of these treatments is
shown to be effective, it is unknown in which patients any one of these
treatments is most effective. Also it is unknown if there is synergism
among these treatments. An important study titled Claudication:
Exercise Vs. Endoluminal Revascularization (CLEVER), sponsored
by the National Heart, Lung and Blood Institute of the National
Institutes of Health,
6
is currently addressing the treatment issue. This
study is designed to assess the effect of the three aforementioned stan-
dard PAD treatments on maximal walking duration. The premise of this
study is that there is equipoise between these treatment modalities,
meaning that although there is improvement with each of the modalities,
it is not clear which treatment is best in a given patient. The CLEVER
study is attempting to determine which of these treatments is best for
patients with PAD located in the aorto-illiac region, with respect to their
efficacy (measured by walking time and quality of life questionnaires),
safety, and cost-effectiveness. This is an excellent example of compara-
tive-effectiveness research. Currently there are more than 100 patients
randomized and study enrollment closure is anticipated some time in
2011, with results to be reported in 2013.
The CLEVER study has the potential to impact the use of supervised
exercise training as a treatment therapy for these patients. Several years
ago a Current Procedural Terminology (CPT) code was established for
PAD rehabilitation. The code (93668) was developed in response to a
preponderance of efficacy data in favor of supervised exercise training.
7
Specifically the code refers to exercise training being performed in a
rehabilitation setting. However, to date this CPT code is not reimbursed
by Medicare. This is despite excellent data on the cost-effectiveness of
supervised exercise versus percutaneous transluminal angioplasty (PTA)
with respect to the cost of treatment relative to the gain in meters
walked at six months post intervention.
7
Importantly, the CPT code is specific to supervised exercise. In fact,
supervised exercise totaling 30 to 45 minutes performed at least 3
times per week for 12 weeks has a Class IA rating for lower extremity
PAD rehabilitation in the most recent ACC/AHA Guidelines on the
treatment of PAD.
5
A Class IA rating means that supervised exercise
training is shown consistently in randomized, controlled studies to be
effective as a means of improving PAD symptoms during exercise and
allowing individuals to walk further without pain. A meta-analysis of 21
studies showed that supervised exercise improves pain free walking dis-
tance by 180% and total walking distance by 120%.
3
Unfortunately,
there is little evidence to support the common physician recommenda-
tion of go home and walk and no evidence that this approach is supe-
rior to supervised exercise training.
5
It is possible a primary hindrance
of home exercise for improvement in patients with symptomatic PAD is
associated with the necessity to endure pain while walking. The typical
PAD exercise training protocol calls for ambulation to modest or mod-
The most recent American Heart Association
fact sheet on lower extremity peripheral
arterial disease (PAD) reports that about 8
million Americans are afflicted.
2
About 10% to
15% of these individuals become symptomatic
(i.e., intermittent claudication) when they
walk.
4
LOWER EXTREMITY
PERIPHERAL ARTERIAL
DISEASE AND EXERCISE
BY JONATHAN K. EHRMAN,
Ph.D., FACSM, CES
A PERSPECTIVE ON
CLINICAL COLUMN
CNews20.final6.0 10/29/10 8:19 AM Page 12
ACSMS CERTIFIED NEWS JULYSEPTEMBER 2010 VOLUME 20:3 13
erate pain to a level 1 or 2 on the claudication scale (see Figure) and is
followed by rest until the pain is alleviated. This process is repeated until
30 to 60 minutes of walking time is completed.
1
It is possible that super-
vision allows for encouragement of the patient to tolerate the pain
which is necessary for improvement. Other factors such as patient edu-
cation and the social atmosphere of a supervised exercise setting also
may play an important role.
Currently it is unknown if exercise training in patients with sympto-
matic PAD will improve associated chronic disease risk profiles or
reduce the risk of mortality. For instance, in those with concomitant dia-
betes, will exercise training reduce the risk of future chronic limb
ischemia and amputation? Theoretical data exists that daily exercise
training can improve blood pressure control, the lipid profile, and
glycemic control in patients with PAD.
5
At this time supervised exercise
training should be a goal of every patient with symptomatic PAD to alle-
viate symptoms and improve quality of life. In fact, regular walking
should be a goal for all individuals. The Phase III cardiac rehabilitation set-
ting is optimal for PAD exercise rehabilitation as these programs are typ-
ically low-cost and provide a level of supervision. In those enrolled in
PAD rehabilitation it is important to apply the PAD rehabilitation CPT
code in the billing process. This will allow important information to be
accrued for use in future determinations of potential reimbursement for
PAD rehabilitation.
About the Author
Jonathan K. Ehrman, Ph.D., FACSM, CES, is the
associate program director of Preventive
Cardiology at Henry Ford Hospital, Detroit MI.
He also is the director of the hospitals Clinical
Weight Management Program. He has served on
ACSMs Committee of Certification and Registry
Board since 2000, was chair of the Clinical
Exercise Specialist Committee and is certified both
as an ACSM Clinical Exercise Specialist and a Program Director. He is
the senior editor of the 6th edition of ACSMs Resource Manual for
Guidelines for Exercise Testing and Prescription and is the Umbrella
Editor for the next editions (2013 release date) of the ACSM certifica-
tion texts.
References
1. American College of Sports Medicine. ACSMs Guidelines for Exercise
Testing and Prescription. 8th ed. Baltimore: Lippincott Williams &
Wilkins, 2010. ps. 120 and 260.
2. American Heart Association. Heart Disease and Stroke Statistics-2009
Update. Dallas, TX; American Heart Association; 2009. p. 21 Available at
http://www.americanheart.org/downloadable/heart/1240250946756LS-
1982%20Heart%20and%20Stroke%20Update.042009.pdf.
Accessed August 23, 2010.
3. Gardner AW, Poehlman ET. Exercise rehabilitation programs for the
treatment of claudication pain: a meta-analysis. JAMA 1995;274:975-80.
4. Hirsch AT , Criqui MH, Treat-Jacobson D, et al. Peripheral arterial dis-
ease detection, awareness, and treatment in primary care. JAMA.
2001;286:1317-1324.
5. Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA Guidelines for the
Management of Patients with Peripheral Arterial Disease (Lower
Extremity, Renal, Mesenteric, and Abdominal Aortic): A Collaborative
Report from the American Association for Vascular Surgery/Society
for Vascular Surgery, Society for Cardiovascular Angiography and
Interventions, Society of Interventional Radiology, Society for Vascular
Medicine and Biology, and the American College of
Cardiology/American Heart Association Task Force on Practice
Guidelines (Writing Committee to Develop Guidelines for the
Management of Patients With Peripheral Arterial Disease). J Am Coll
Cardiol 2006;47;e1-e192.
6. Murphy TP, Hirsch AT, Ricotta JJ, et al. The Claudiation: Exercise Vs.
Endoluminal revascularization (CLEVER) study: Rationale and methods. J
Vasc surg 2008;47(6):1356-1363.
7. Treesak C, Kasemsup V, Treat-Jacobson D, et al. Cost-effectiveness of exer-
cise training to improve symptoms in patients with peripheral arterial dis-
ease. Vasc Med 2004;9:279-285.
Figure. Claudication Scale
Rating Description
1 Definite discomfort or pain, but only at
initial or modest levels (established, but
minimal)
2 Moderate discomfort or pain from which the
patients attention can be diverted (e.g., by
conversation)
3 Intense pain (short of grade 4) from which
the patients attention cannot be diverted
4 Excruciating and unbearable pain
* reprint from 1
choice for them. For example, I want to walk three days a week
because I can fit it in (the five days recommended by my trainer is
too much). I am more relaxed and that helps me be more present
and productive at work and home. I do not want to miss out on the
benefits of my walks and I have backup strategies in place.
Seizing the wheel leads to authenticity and increased self-motiva-
tion. It fosters competence. It helps our clients build and sustain the
energy and strength to handle whatever life throws their waylead-
ing to a life of thriving and well-being.
About the Author
Margaret Moore/Coach Meg, MBA, is the
founder & CEO of Wellcoaches Corporation, a
strategic partner of ACSM, widely recognized as
setting a gold standard for professional coaches
in health care. She is co-director, Institute of
Coaching, at McLean Hospital/ Harvard Medical
School. She co-authored the ACSM-endorsed
Lippincott, Williams & Wilkins Coaching
Psychology Manual, the first coaching textbook
in health care. (www.wellcoaches.com www.instituteofcoaching.org
www.coachmeg.com coachmeg@wellcoaches.com)
References
1. Deci, E.L. & Flaste, R. (1995). Why we do what we do: Understanding
self-motivation. New York: Penguin Books.
2. Ryan, R. M. &. Deci, E. L. (2000). Self-determination theory and the
facilitation of intrinsic motivation, social development, and well-
being. American Psychologist, Vol. 55, No. 1, 68-78.
Coaching News continued from page 9
S E L F - T E S T A N S W E R K E Y F O R P A G E 1 5
Q U E S T I O N
1 2 3 4 5 6
T E S T 1 : B B D A C
T E S T 2 : D A B B A
T E S T 3 : T R U E T R U E B A C C
T E S T 4 : B D A C B
CNews20.final:ACSM template 10/26/10 9:09 AM Page 13
With health care costs on the rise, and employee
wellness at the forefront of most benefits discus-
sions, more and more companies are seeking out
workplace Wellness Specialists to provide
employee education and increase presenteeism,
while helping companies improve their bottom
line. In 2007, the International Health, Racquet &
Sportclub Association (IHRSA) introduced the
Workforce Health Improvement Program (WHIP)
Act, in an effort to make employee wellness and
exercise programs tax-free and more widely rec-
ognized as a needed benefit. For more informa-
tion on the WHIP Act, log onto IHRSAs home-
page at www.ihrsa.org
According to the U.S. Centers for Disease Control and Prevention
(CDC), people who participate in moderate-intensity or vigorous-
intensity physical activity on a regular basis lower their risk of coronary
artery disease, stroke, non-insulin dependent (type 2) diabetes, high
blood pressure, and colon cancer. Yet, according to a 2009 CDC
research study on physical activity,
3
more than 50% of American adults
do not get enough physical activity to provide health benefits.
A recent study on presenteeism
4
notes that the top 12 health con-
ditions that unfavorably impact work productivity were allergies,
arthritis, asthma, cancer, depression, diabetes, heart problems, hyper-
tension, headaches, respiratory disorders, skin conditions, and
back/neck/spinal injuries.
Many organizations continue to be concerned with the number of
employees who are affected with these conditions and how that
impacts not only days/time spent out of work, but how it translates
in to overall productivity. The data published below, adapted from
research collected by the International Journal of Workplace
Health Management
5
address health risks as well as healthy behav-
iors, further illustrating the relationship between healthy lifestyle
habits and productivity (see Figure).
Wellness Specialists are health professionals with diverse back-
grounds; such as Registered Dieticians, Certified Personal Trainers,
Clinical Exercise Specialists, and Certified Well Coaches. As dedicat-
ed certif ied health and fitness professionals, it has always been our
mission to teach, coach, and educate our clients on the benefits of
regular physical activity, proper diet, and healthy habits. We have the
power to address and help modify and or correct many if not all of
the above mentioned factors that are affecting individuals in the
workplace. Why then, as of late, are companies suddenly labeling
wellness a hot-button issue? Recent studies conducted by the
National Safety Council have shown that at least 25% of the health
care costs incurred by working adults can be attributed to modifiable
health risks, such as increased stress, inadequate physical activity lev-
els and poor nutritional habits (www.nsc.org).
According to the National Institute for Occupational Safety and
Health (www.cdc.gov/niosh) stress-related disorders are fast becom-
ing the most prevalent reason for worker disability, costing between
$20 billion and $30 billion annually due to worker absenteeism. A
recent meta-analysis conducted out of Harvard
1
suggests that medical
costs can decrease by about $3.27 for every dollar spent on worksite
wellness and disease prevention, and that absenteeism costs can be
decreased by about $2.73 for every dollar spent. These return on
investment findings suggest that the implementation of employee
wellness programs could prove beneficial for budgets as well as over-
all health outcomes. By becoming more familiar with the ever-grow-
ing list of career opportunities that are emerging in corporate well-
ness, we as health and fitness professionals are able to expand our tal-
ents in areas that compliment our expertise. These opportunities
arising in our industry are exciting for both the newly certified and
experienced professional. Certified Health, Fitness, and Nutrition
Specialists are being called upon to design motivating initiatives such
as smoking cessation programs, walking programs, heart healthy aer-
obic classes, ergonomics awareness programs, and mind/body relax-
ation classes such as stretching and Yoga. In addition, city agencies
such as police and fire departments, government offices, public
schools, and universities also are hiring health and fitness profession-
als to facilitate wellness and educational programs. In 2006, 19% of
companies with 500 or more employees reported offering employee
wellness programs, with that number increasing to 77% of larger
companies who offered some form of worksite wellness related initia-
tive in 2008.
2
According to a recent article in the New York Times,
6
titled Carrots, Sticks and Lower Premiums by Steve Lohr; the busi-
ness of worksite wellness programs is starting to boom, and some
companies are offering incentives to their employees based on their
involvement. In fact, a fledgling pay for prevention industry is begin-
ning to emerge, offering employers ways to reward workers with
WELLNESS ARTICLE
ENHANCING QUALITY OF LIFE
FROM 9 TO 5 AND BEYOND
BY Nikki Carosone M.S., ACSM CPT
THE EVOLUTION OF WORKSITE WELLNESS
Evolution (continued on page 16)
Figure.
14 ACSMS CERTIFIED NEWS JULYSEPTEMBER 2010 VOLUME 20:3
CNews20.final:ACSM template 10/26/10 9:09 AM Page 14
ACSMS CERTIFIED NEWS JULYSEPTEMBER 2010 VOLUME 20:3 15
SELF-TEST #1 (1 CEC):The following questions are
from Fitness Assessment and Exercise Prescription: Are
Your Assessments Providing the Information You
Need? published on page 3.
1. Which two points regarding the role of fitness
assessments were discussed?
a. Following club protocols and motor learning
b. Individualizing assessments and motor learning
c. Following industry standards and individualizing
assessments
d. Motor learning and physical conditioning
assessments
2. The primary adaptation during the first 4 to 6 weeks
of a muscular training program is the development of
__________________.
a. motor sufficiency b. motor pathways
c. muscle hypertrophy d. muscle hyperplasia
3. Which of the following are components of Fleishmans
physical proficiency abilities?
a. Reaction time, extent flexibility, and explosive
strength
b. Trunk strength, multi-limb coordination, and
dynamic flexibility
c. Gross body coordination, stamina, and reaction
time
d. Explosive strength, extent flexibility, and gross
body coordination
4. Which of the following are components of Fleishmans
perceptual motor abilities?
a. Reaction time, multi-limb coordination, and rate
control
b. Multi-limb coordination, trunk strength, and
dynamic flexibility
c. Gross body coordination, reaction time, and
control precision
d. Static strength, dynamic strength, and rate control
5. Fitness professionals would benefit from some fine-
tuning of their fitness assessments with respect to
alignment with the clients ________.
a. goals, health history, and current desire to exercise
b. current desire to exercise and willingness to
participate
c. goals, health history, and prior physical activity
experience
d. prior physical activity experience and current
desire to exercise
SELF-TEST #2 (1 CEC): The following questions
are taken from Is Functional Training Really
Functional? published on page 5.
1) A study by Fiatarone et al. found that nursing home
patients improved their functional scores on a test of
walking and balance improved by approximately ___
after performing 3 sets of 8 repetitions on a machine
leg extension apparatus for 8 weeks.
a) 10% b) 26%
c) 39% d) 48%
2) A study by Cressey et al. attributed a decrease in
performance improvements in elite soccer players
who performed exercises on an unstable surface to:
a) a reprogramming of neuromuscular patterns that
chronically impairs stretch-shortening cycle
function.
b) a reduction in muscle hypertrophy.
c) an inhibition of calcium release from the
sarcoplasmic reticulum.
d) an increase in soft tissue injuries to the knee joint.
3) According to a study by Behm et al. , a limitation of
unstable surface training is that:
a) it reduces core activation.
b) it reduces force output in muscles of the
extremities.
c) it increases the potential for injury.
d) it does not allow for optimal range of motion
about a joint.
4) The Specific Adaptation to Imposed Demands
(SAID) principle dictates that:
a) multi-joint movements should be performed
before single joint movements.
b) optimal transfer of the exercise benefit is achieved
when movements most closely match those of a
given task.
c) muscles must be constantly challenged beyond
their present capacity.
d) program variables should be varied over time to
prevent plateau.
5) According to McKeon et al. , incorporating
approximately ________ unstable surface exercises into
a routine may be ideal for optimizing static and dynamic
balance.
a) 25% b) 35%
c) 50% d) 75%
SELF-TEST #3 (1 CEC): The following questions are
taken from New Thoughts on what Really Causes
Heart Disease and How Exercise Helps Beyond
Traditional Risk Factors published on page 7.
1. Postprandial is that period of time following a meal.
True False
2. Endothelial function includes those activities that
protect the artery from developing atherosclerosis.
True False
3. The substance produced in the endothelial cells that
protects arteries from developing atherosclerosis is
a. eNOS. b. NO.
c. L-Argenine. d. ONOO
-.
4. A high-fat meal harms the endothelium by
a. Increasing oxidative stress from elevated fats.
b. Increasing NO.
c. Decreasing insulin.
d. Increasing lipemia which decreases eNOS.
5. Nutrients that are harmful to the endothelial lining
(of a healthy adult) include:
a. Polyunsaturated fats. b. Carbohydrates.
c. Transfats. d. Simple Sugars.
6. Exercise can reduce atherosclerosis development
through what mechanisms?
a. Decreasing insulin sensitivity
b. Increasing oxidative stress
c. Decreasing lipemia
d. Decreasing NO
SELF-TEST #4 ( 1 CEC) : The following questions
were taken from The Evolution of Wellness...
published in this issue on page 14.
1. According to the U.S. Centers for Disease Control
and Prevention, what percentage of American adults
are not getting enough physical activity?
a. 40% b. 50%
c. 25% d. 15%
2. According to the National Safety Council which of
these health risks are considered modifiable?
a. Increased stress levels
b. Inadequate physical activity levels
c. Poor nutritional habits
d. All of the above
3. Medical costs can fall by as much as this amount for
every dollar spent on worksite wellness and disease
prevention.
a. $3.27 b. $2.50
c. $3.10 d. $2.77
4. In 2006, 19% of companies with 500 or more
employees reported offering employee wellness
programs. In 2008, that number increased to _____.
a. 57% b. 68%
c. 77% d. 72%
5. In 2007, IHRSA introduced this Act, in an effort to
make employee wellness and exercise programs tax-
free and more widely recognized as a needed benefit.
a. Health Improvement Prevention Program (HIPP)
Act
b. Workforce Health Improvement Program (WHIP)
Act
c. Wellness Health Improvement Benefit (WHIB)
Act
d. Workplace, Homeplace, Integration Prevention
Program (WHIPP)
JulySeptember 2010 Continuing Education Self-Tests
Credits provided by the American College of Sports Medicine CEC Offering Expires September 30, 2011
To receive credit, circle the best answer for each question, check your answers against the answer key on page 13,
and mail entire page with check or money order payable in U.S. dollars to: American College of Sports Medicine,
Dept 6022, Carol Stream, IL 60122-6022
ACSM Member (PLEASE MARK BELOW) Please Allow 4-6 weeks for processing of CECs
[ ] Yes-$15 TOTAL $_________________
[ ] No- $20 ($25 fee for returned checks)
ID # __________________ (Please provide your ACSM ID number)
PLEASE PRINT OR TYPE REQUESTED INFORMATION
NAME
ADDRESS
CITY STATE ZIP
BUSINESS TELEPHONE E-MAIL
JulySeptember 2010 Issue EXPIRATION DATE: 09/30/11 SELF-TESTS SUBMITTED AFTER THE EXPIRATION DATE WILL NOT BE ACCEPTED Federal Tax ID number 23-6390952
Tip: Frequent self-test participants can find their ACSM ID number located on any ACSM CEC verification letter.
ACSMS
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NEWS

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cash or reduced insurance premiums for participating in these pro-
rams and leading healthier lifestyles. Among the industry leaders are
RedBrick Health, Tangerine Wellness, and Virgin HealthMiles. And,
some big companies, like Safeway and General Electric, are experi-
menting independently with financial incentives to encourage employ-
ees to adopt healthy habits and to eliminate unhealthy ones. For
example, General Electric employees who smoke, pay an extra $625
a year for health insurance.
6
The benefits from these programs are becoming more and more
obvious, with side effects such as heightened alertness, fewer injuries,
and visible improvements in appearance and overall well-being. It is no
wonder that more and more employers are trying to provide more
access to health and wellness programs to their employees.
According to a recent study conducted by MetLife,
7
37% of employ-
ers now offer some type of wellness-based program, which is up from
33% in 2008 and 27% in 2005.
In light of these recent studies, it is becoming easier to illustrate
the need for worksite wellness programs. A new finding in this years
MetLife study on leveraging health and wellness programs shows
staggering satisfaction results on both the employee and employer
front. Results showed that in companies where health and wellness
programs are offered, nearly half of employers (48%) and a whop-
ping 58% of employees reported that these programs translate into
increased productivity and employee satisfaction.
7
These are very
exciting times for us as health and wellness professionals. We have
the opportunity to help companies keep their employees healthier,
happier and more productive!
ABOUT THE AUTHOR
Nikki Carosone, M.S. ACSM cPT, is a general
manager and wellness specialist with Plus One Health
Management in New York City. Nikki also is an
associate professor of Exercise Physiology and
Exercise Prescription at Long Island University,
Brooklyn Campus. Her expertise is focused in the areas
of wellness, physical activity, and, health promotion.
References
1. Baicker, K, Cutler, D, Song, Z in Health Affairs; Workplace Wellness
Programs Can Generate Savings
http://content.healthaffairs.org/content/vol29/issue2/index.dtl
(February 2010)
2. Capps, K, of Health2 Resources and Harkey, J. Pd.D., of Harkey
Research for Employee Health & Productivity Management Programs:
The Use of Incentives; A Survey of Major U.S Employers
www.incentone.com/files/2008-surveyresults.pdf (June 2008)
3. Centers For Disease Control And Prevention; Physical Activity
Resources For Health Professionals
http://www.cdc.gov/physicalactivity/professionals/data/index.html
4 Econtech Pty Ltd. Economic modeling of the cost of Presenteeism in
Australia
http://www.econtech.com.au/information/Social/Medibank_Presente
eism_FINAL.pdf (May 2007)
5. Internation Journal of Workplace health Management Voloume 1,
Issue 1 http://www.emeraldinsight.com/journals.htm?issn=1753-
8351&PHPSESSID=5bc3muejulenmbj75ta3vm66f6
6 Lohr Stephen ; Carrot Sticks and Lower premiums for The New York
Times March 26, 2010
7. MetLife : The 8th Annual Study of Employee Benefit Trends
http://www.metlife.com/assets/institutional/services/insights-and-
tools/ebts/Employee-Benefits-Trends-Study.pdf (April 2010)
Evolution continued from page 14
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